Short-term safety, function, and quality of life in patients treated with Univers Revers prosthesis: a multicenter 2-year follow-up case series.

BACKGROUND: The use of reverse total shoulder arthroplasty (RTSA) has dramatically increased in recent years with the advent of new prosthesis designs regularly entering the market. We define the rate of local complications during the first 2 years after RTSA with the Univers Revers prosthesis and describe the changes in radiologic outcomes, as well as function, pain, satisfaction, and quality of life. METHODS: This multicenter, prospective case series included rotator cuff tear arthropathy patients who underwent RTSA with the Univers Revers. Incidence percentages of complications and pathologic radiographic changes were documented. Mixed-model linear regression was used to examine changes in range of motion, shoulder function (Constant score, Shoulder Pain and Disability Index, Subjective Shoulder Value), and quality of life (EQ-5D-5L [European Quality of Life 5 Dimensions 5 Level] and EQ-VAS [EuroQol Visual Analog Scale]). RESULTS: Of 187 patients, 59.4% were women, and the mean age was 75.3 years (range, 56-91 years). Twenty-five percent of patients had a postoperative complication; 5 complications were severe (2.7%, 5 of 187), whereby 2 were implant related (1.1%; 95% confidence interval [CI], 0.1%-3.8%). The incidence of scapular notching was 10.6% (95% CI, 6.5%-16%). After 2 years, abduction, flexion, and abduction strength improved by 54° (95% CI, 50°-58°), 57° (95% CI, 53°-60°), and 5 kg (95% CI, 4-5 kg), respectively (P < .001), whereas external rotation at 0° (1°; 95% CI, -1° to 3°) did not improve (P = .4). The Constant score improved by 39 (95% CI, 38-41); Shoulder Pain and Disability Index, by 50 (95% CI, 47-52); and Subjective Shoulder Value, by 43 (95% CI, 41-45) (P < .001). Furthermore, the EQ-5D-5L index value improved by 0.31 (95% CI, 0.30-0.33), and the EQ-VAS score improved by 16 (95% CI, 14-18) (P < .001). CONCLUSION: Our case series showed a low complication rate with a consistent clinically relevant and statistically significant improvement across most clinical and patient-reported outcomes for the Univers Revers. Long-term safety requires further investigation.

Re-intervention and revision rates following primary reverse total shoulder arthroplasty - review of a local shoulder arthroplasty registry.

PURPOSE: Our primary aim was to describe the re-intervention and revision rates after primary reverse shoulder arthroplasty (RSA) documented in a local shoulder arthroplasty registry. We also identify the main indication for revision and re-intervention, which may be relevant for patient outcome post-RSA. METHODS: Since July 2006, RSAs are consecutively documented in our clinic registry and prospectively controlled with follow-ups. Any intervention after primary RSA requiring a return to the operating room for any shoulder-related indication was termed a re-intervention. Revisions were defined as surgeries involving any exchange, removal, or addition of at least one component. The study endpoints were survival rates at two, five and ten years follow-up for both definitions. RESULTS: Until July 2017, 63 from a total of 1480 primary RSAs required at least one re-intervention and 33 patients had a revision. Open reduction and internal fixation for fractures around the implant (n = 14) were the predominating indications for re-intervention. The re-intervention rate for instability was 0.5%. For re-interventions, survival rates were 97.7, 95.4 and 90.8% at two, five and ten years, respectively, and the respective rates for revisions were 98.7, 97.5 and 95.3%. CONCLUSION: The revision rate after primary RSA for our patient registry is low. A relevant number of additional interventions were noted that did not require any component revision but may impair the final outcome post-RSA. By only reporting revision rates, the number of post-RSA re-interventions is clearly underestimated. We recommend the documentation of all events leading to any re-intervention in arthroplasty registries.

Repair of Lafosse I subscapularis lesions brings no benefit in anterosuperior rotator cuff reconstruction.

PURPOSE: Optimal management of partial anterosuperior rotator cuff tears is unknown. Our aim was to compare clinical and subjective outcomes of supraspinatus (SSP) repair patients treated with or without repair of an associated superior subscapularis (SSC) partial tear. METHODS: SSP repair patients with an associated partial (Lafosse I) tear of the superior SSC tendon were retrospectively examined. Baseline and operative data and the outcomes of shoulder range of motion (ROM), pain level, strength, Constant-Murley Score, complications at 6 months as well as patient-reported Oxford Shoulder Score, Subjective Shoulder Value, and satisfaction at 6- and 24-month post-surgery were compared between patients with and without a repaired SSC tear. Mixed models and propensity-score matching were used to adjust baseline group differences. RESULTS: Of 75 eligible patients, 34 had an SSC repair and were younger with better baseline function. Non-repair surgeries were significantly shorter by 34 min (95% CI 23-45; p < 0.001). There were no group differences in the clinical and patient-rated outcome scores at both follow-ups (n.s.) as well as in pain, muscle strength in abduction, ROM, the 6-month complication risk (risk difference - 1.9%), and satisfaction with postoperative shoulder condition (n.s.). CONCLUSION: We could not show a functional or subjective benefit of repairing cranial partial tears of the SSC tendon over debridement only in the setting of an SSP reconstruction with 24 months of follow-up. A longer operative duration is expected if a partial SSC tear repair is performed. LEVEL OF EVIDENCE: III.

Core set of unfavorable events of shoulder arthroplasty: an international Delphi consensus process.

BACKGROUND: Shoulder arthroplasty (SA) complications require standardization of definitions and are not limited to events leading to revision operations. We aimed to define an international consensus core set of clinically relevant unfavorable events of SA to be documented in clinical routine practice and studies. METHODS: A Delphi exercise was implemented with an international panel of experienced shoulder surgeons selected by nomination through professional societies. On the basis of a systematic review of terms and definitions and previous experience in establishing an arthroscopic rotator cuff repair core set, an organized list of SA events was developed and reviewed by panel members. After each survey, all comments and suggestions were considered to revise the proposed core set including local event groups, along with definitions, specifications, and timing of occurrence. Consensus was reached with at least two-thirds agreement. RESULTS: Two online surveys were required to reach consensus within a panel involving 96 surgeons. Between 88% and 100% agreement was achieved separately for local event groups including 3 intraoperative (device, osteochondral, and soft tissue) and 9 postoperative event groups. Experts agreed on a documentation period that ranged from 3 to 24 months after SA for 4 event groups (peripheral neurologic, vascular, surgical-site infection, and superficial soft tissue) and that was lifelong until implant revision for other groups (device, osteochondral, shoulder instability, pain, late hematogenous infection, and deep soft tissue). CONCLUSION: A structured core set of local unfavorable events of SA was developed by international consensus to support the standardization of SA safety reporting. Clinical application and scientific evaluation are needed.

Glenosphere size in reverse shoulder arthroplasty: is larger better for external rotation and abduction strength?

BACKGROUND: The role of glenosphere size in reverse shoulder arthroplasty (RSA) may be important in prosthetic stability, joint kinematics, rotator cuff tension and excursion, scapular impingement, humeral lateralization, deltoid wrap, and the occurrence of "notching." This study compared short- and midterm clinical and radiographic outcomes for 2 different glenosphere sizes of a single RSA type with respect to implant positioning, glenoid size, and morphology. METHODS: This retrospective analysis included 68 RSA procedures that were prospectively documented in a local register during a 5-year postoperative period. Two glenosphere diameter sizes of 36 mm (n = 33) and 44 mm (n = 35) were used. Standard radiographs were made preoperatively (ie, baseline) and at 6, 12, 24, and 60 months after surgery. Range of motion, strength, the Constant-Murley score, and the Shoulder Pain and Disability Index were also assessed at all follow-up visits. The effect of glenosphere size on measured outcomes was adjusted for baseline values, patient gender, and humeral head diameter. RESULTS: No significant differences were found in the functional scores between treatment groups at all follow-up assessments. At the 12-month follow-up, patients with a 44-mm glenosphere had greater external rotation in adduction (mean difference, 12°; P = .001) and abduction strength (mean difference, 1.4 kg; P = .026) compared with those with the smaller implant. These differences remained at 60 months. Scapular notching was observed in 38% of all patients, without any relevant difference between the groups. CONCLUSION: An increase in glenosphere diameter leads to a clinically moderate but significant increase in external rotation in adduction and abduction strength at midterm follow-up.

Return to sports after reverse shoulder arthroplasty-the Swiss perspective.

PURPOSE: This patient survey evaluated the return to previous sports activities in Swiss patients up to five years after reverse shoulder arthroplasty (RSA). METHODS: We screened our local shoulder arthroplasty registry for patients registered with a unilateral RSA due to rotator cuff deficiency between May 2010 and May 2015. Revision cases and patients already known as unwilling or unable to complete a German language questionnaire were excluded. Eligible patients received a paper questionnaire asking about their past and current sports activities, return time point and level of activity. RESULTS: Of 305 patients, 89% responded at a mean post-operative follow-up of 2.9 years (SD 1.1). The respondents had a mean age of 77.1 years (SD 7.8) and included 62% females. The overall rate of patients returning to a previous sports activity was 77%. Sixty-one percent (166/271) participated in regular sports activities before the onset of their shoulder disorders. After RSA, 47% (127/271) participated in at least one sport type with the most frequent activities including hiking (66), swimming (53), cycling (45) and callisthenics (43). Most patients carried out their main sports activity after surgery with a moderate level of intensity (83%) and between one to three times per week (69%). Forty-two percent of the respondents indicated that returning to sports was among their key demands after RSA. CONCLUSIONS: Returning to previous sports activities is an important expectation of RSA patients, and the majority do. Patient expectations of post-operative sports activity need to be addressed when planning RSA.

Radiological and functional 24-month outcomes of resurfacing versus stemmed anatomic total shoulder arthroplasty.

PURPOSE: This study compared clinical and radiographic outcomes of patients undergoing resurfacing total shoulder arthroplasty (TSA) with those treated with a stemmed TSA. METHODS: Patients with primary osteoarthritis who underwent humeral resurfacing (RES) or stemmed (STA) TSA were identified in our shoulder arthroplasty register for retrospective analysis. Standard radiographs and clinical/patient-rated assessments were made up to 24 months post-surgery. Implant revisions were assessed. Patients were frequency-matched in a 1:1 (RES:STA) ratio based on gender and age, and compared with regard to operation time and shoulder function (Constant, SPADI and Quick DASH scores). Mixed models with statistical adjustments were applied. RESULTS: From 2006 to 2014, 44 RES and 137 STA operations were performed in 157 patients; one and two revisions were recorded in the RES and STA group, respectively. The final matched cohort included a total of 69 patients and 37 operations per treatment group. Resurfacing TSA was 17 min shorter (95%CI: 5-28) compared to the stemmed procedure (p = 0.005). RES and STA patients showed significant functional improvement six months post-implantation, yet all measured scores did not differ between the groups at 2 years (p ≥ 0.131). The status of static centering of the humeral head, acromiohumeral distance, and a lack of signs of implant loosening were also similar between treatments. CONCLUSION: Similar 24-month post-operative radiological and functional outcome is achieved by RES and STA patients, even with a shorter RES surgery time. Larger cohorts and longer follow-up are required to better assess implant survival.

Towards standardised definitions of shoulder arthroplasty complications: a systematic review of terms and definitions.

INTRODUCTION: A transparent, reliable and accurate reporting of complications is essential for an evidence-based evaluation of shoulder arthroplasty (SA). We systematically reviewed the literature for terms and definitions related to negative events associated with SA. MATERIALS AND METHODS: Various biomedical databases were searched for reviews, clinical studies and case reports of complications associated with SA. Any general definition of a complication, classification system, all reported terms related to complications and negative events with their definitions were extracted. Terms were grouped and organised in a hierarchical structure. Definitions of negative events were tabulated and compared. RESULTS: From 1086 initial references published between 2010 and 2014, 495 full-text papers were reviewed. Five reports provided a general definition of the term "surgical complication" and 29 used a classification system of complications. A total of 1399 extracted terms were grouped based on similarities and involved implant or anatomical parts. One hundred and six reports (21.4%) defined at least one negative event for 28 different terms. There were 64 definitions related to humeral or glenoid loosening, and 25 systems documenting periprosthetic radiolucency. Other definitions considered notching, stress shielding, implant failure and tuberosity malposition. CONCLUSIONS: A clear standardised set of SA complication definitions is lacking. Few authors reported complications based on definitions mainly considering radiological criteria without clinical parameters. This review should initiate and support the development of a standardised SA complication core set.

Conversion to hemiarthroplasty as a salvage procedure for failed reverse shoulder arthroplasty.

BACKGROUND: Optimal treatment of a failed reverse shoulder arthroplasty (RSA) is unclear. In the case of poor glenoid bone stock, retaining a RSA may be infeasible. We report our experience with conversions to hemiarthroplasty. METHODS: Within 7 years, 16 patients underwent conversion to hemiarthroplasty after failed RSA. All patients had insufficient bone stock for reimplantation of another RSA. Standard radiographs and Constant, Shoulder Pain and Disability Index, and the 11-item version of the Disabilities of the Arm, Shoulder and Hand scores were assessed preoperatively and up to a minimum of 24 months after surgery. Postoperative superior migration and complications were also documented. RESULTS: Glenoid loosening was the primary reason for RSA failure in 11 patients. Three required revision surgery because of infection. Postoperative functional outcome was generally poor at the latest follow-up, with mean Constant, Shoulder Pain and Disability Index, and 11-item version of the Disabilities of the Arm, Shoulder and Hand scores of 25, 37, and 63 points, respectively. Baseline pain also did not improve. Medialization progressed beyond the coracoid in 6 patients, and complete anterosuperior escape was reported in 3 patients. Three postoperative complications were recorded by the final follow-up, including 2 periprosthetic humeral fractures treated conservatively and 1 patient with painful humeral component medialization leading to resection arthroplasty. CONCLUSION: With excessive bone stock loss, hemiarthroplasty remains an option, despite the associated risks of uncertain pain relief and poor functional outcome. This technique offers a lower likelihood of undertaking further surgical interventions within the short-term to midterm postoperative period. Nevertheless, resection arthroplasty may still be considered another valuable solution.

Risk of insufficient internal rotation after bilateral reverse shoulder arthroplasty: clinical and patient-reported outcome in 57 patients.

BACKGROUND: Bilateral reverse shoulder arthroplasty (RSA) is controversial because of potential rotational deficits impairing daily living activities. We assessed achievement of insufficient internal rotation (IR) and associated factors in bilateral RSA patients. METHODS: Fifty-seven staged bilateral RSA patients with a minimum of 1 year of follow-up after the second intervention were identified from our local monocentric register. Shoulder range of motion (including IR using the Apley scratch test), strength, and Constant and Shoulder Pain and Disability Index scores were assessed preoperatively and 6, 12, and 24 months postoperatively. RESULTS: Before surgery, both shoulders were similar regarding imaging parameters, but first operated shoulders tended to have poorer function. One year after the first RSA, 21% of patients had insufficient IR (not reaching the lumbosacral junction) compared with 33% after the second intervention (P = .180). At 2 years, 5% of patients had insufficient IR on both sides. Patients with insufficient IR on the second side at baseline (relative risk [RR], 1.8 [1.0-3.2]) and patients with insufficient IR 1 year after the first RSA (RR, 3.0 [1.6-5.6]) were more likely to have insufficient IR 1 year after the second RSA. Constant and Shoulder Pain and Disability Index scores and abduction of the second side were significantly worse 1 year after the second RSA (P ≤ .047); at 2 years, there were no differences in functional outcome between shoulders. CONCLUSION: A minority of bilateral RSA patients did not achieve sufficient IR on at least 1 side. Staged surgery is justified, particularly when the outcome of the initial operation is satisfactory.

Patterns of proximal humeral bone resorption after total shoulder arthroplasty with an uncemented rectangular stem.

BACKGROUND: The aim of this study was to assess the timing and location of cortical bone resorption after total shoulder arthroplasty with an uncemented rectangular stem and investigate its effect on shoulder function up to 5 years after implantation. METHODS: Between June 2003 and September 2006, 183 consecutive total shoulder arthroplasties were performed, 133 of which received a cementless rectangular stem as indicated by primary or post-traumatic osteoarthritis (OA). The 5-year postoperative follow-up rate was 80%. Standardized radiographic controls and clinical assessments were performed at 6 weeks, 6 months, and 1, 2, and 5 years. RESULTS: Twenty-two patients (17%) showed full-thickness cortical bone resorption, 21 of whom were diagnosed with Sperling zone 2 resorption. The maximum craniocaudal distance of full resorption averaged 19.1 mm (range, 5.6-46.7 mm). The median distance progressed significantly from 9.6 mm to 13.8 mm between 6 and 12 months (P = .005). The risk of bone resorption was 3.1 times higher for post-traumatic OA patients than for those with primary OA. The occurrence of bone resorption increased significantly with increasing stem diameters relative to the humeral diameter. There was no significant effect of bone resorption on functional outcome. CONCLUSION: Full-thickness cortical bone resorption in the proximal posterolateral humerus after receipt of a cementless rectangular stem has a prevalence of 17%, mostly occurring within the first year after surgery. Risk factors include age, post-traumatic conditions, and larger stem sizes relative to the humerus. This is a radiographic phenomenon without significant impairment of function or need for revision within 5 years after surgery.

Osteoid osteoma of the shoulder and elbow: from diagnosis to minimally invasive removal.

PURPOSE: Musculoskeletal tumours are rare in the daily practice of an orthopaedic surgeon or even a shoulder and elbow specialist. Patient complaints are often related to secondary changes to the underlying disease making the correct diagnosis challenging. The goal of this study is to identify key symptoms and findings which should give rise to suspicion of an osteoid osteoma. METHODS: This retrospective study analyses the diagnostic pathway, surgical treatment and clinical outcome of six patients who underwent resection of an osteoid osteoma of the shoulder or elbow joint. RESULTS: Average follow-up was 24 months (range 16-36 months). The neoplasm was often associated with synovitis mimicking a frozen joint causing marked delay in tumour identification. Misdiagnosis led to surgery without addressing the tumour in two cases, making further surgical intervention necessary. Once the tumour was identified and removed the pain resolved rapidly. CONCLUSIONS: In cases of chronic shoulder or elbow pain without an adequate clinical history an underlying cause including rarities such as an osteoid osteoma or other musculoskeletal tumours should be taken into consideration. Particularly in young patients, a magnetic resonance imaging (MRI)-proven hot spot of unknown origin should prompt a computed tomography examination to further clarify the source of pain and stiffness. LEVEL OF EVIDENCE: IV, case series.

Treatment strategies for periprosthetic infections after primary elbow arthroplasty.

BACKGROUND: The goal of this study was to investigate the outcome of different surgical procedures (debridement and retention vs 1- or 2-stage exchange) together with a well-defined antimicrobial regimen. MATERIALS AND METHODS: A total of 236 consecutive patients underwent 262 primary elbow arthroplasties between January 1994 and December 2007. We observed 20 episodes of periprosthetic infections in 19 patients and placed them into 3 groups according to the occurrence of infection after index surgery. A total of 9 early infections (<3 months), 1 delayed infection (3-24 months), and 10 late infections (>24 months) were observed. The treatment among those 3 groups was compared, and the outcome was assessed with a mean follow-up of 60.2 months. RESULTS: In the group with early infections (n = 9), 8 cases were treated by irrigation and debridement and 1 case was treated by a 2-stage exchange without recurrence of infection. The mean Mayo Elbow Performance Score improved from 48.3 points (range, 30-75 points) to 91.7 points (range, 85-100 points). The delayed infection was treated by 1-stage exchange without recurrence of infection. For late infections (n = 10), 3 cases presented recurrence of infection after debridement and irrigation, and the mean Mayo Elbow Performance Score remained nearly unchanged, from 60 points (range, 45-80 points) to 65 points (range, 50-80 points). Eradication of infection could be achieved by staged revision and in 3 cases by debridement. CONCLUSION: Both debridement with retention and staged reimplantation are highly successful for appropriate indications. Staged revisions are successful even against biofilm-active microorganisms, but a prosthesis-free interval of at least 3 months is recommended.

Reverse shoulder arthroplasty as a salvage procedure for failed conventional shoulder replacement due to cuff failure--midterm results.

Our goal was to evaluate the objective and subjective midterm outcome after revision of a failed shoulder arthroplasty with a reverse design prosthesis. Twenty consecutive patients with 21 revisions of a primary shoulder arthroplasty using reverse shoulder prosthesis Delta III(®) were followed up postoperatively for a mean of 46 months including clinical and radiological examination. Complications were recorded and Constant score, DASH and SF36 were assessed. With the numbers given a significant reduction of pain was achieved from 8.7 to 3.0 (p < 0.001). There was a significant improvement of active flexion from 43° to 97° (p < 0.001) and active abduction from 44° to 90° (p < 0.001). However, at the same time, active external rotation with an adducted humerus decreased significantly from 26° to 12° (p = 0.012). The constant score improved significantly from 16.7 to 55.9 (p < 0.001). Sixteen patients (84%) rated their shoulder better or much better than before. In 43% an intraoperative and in 38% a postoperative complication occurred including two late stage infections which required prosthesis removal. Our results support the use of the reverse prosthesis as revision prosthesis. The reverse design helps to compensate functional deficits due to severe soft-tissue damage except active external rotation. Nevertheless, the revision is a technically demanding procedure reflected in a high rate of intraoperative complications. The rate of secondary infections of 10% remains a special concern.

Glenoid Component Loosening in Anatomic Total Shoulder Arthroplasty: Association between Radiological Predictors and Clinical Parameters-An Observational Study.

The mechanisms of glenoid component loosening in anatomic total shoulder arthroplasty (aTSA) are still unclear, and it remains undetermined which specific radiographic features are associated with clinical outcomes. Patients with primary osteoarthritis who underwent aTSA with a stemless implant and a pegged glenoid between January 2011 and December 2016 were extracted from a local registry. Anteroposterior radiographs were evaluated at six, 12, 24 months, and five years post-TSA for lateral humeral offset (LHO), joint gap (JG), acromiohumeral distance (AHD), and radiolucency (modified Franklin score); 147 patients were included. Mixed-model linear regression was used. Both constant score (CS) and subjective shoulder value (SSV) markedly decreased at five years follow-up compared to one year (p < 0.001 for both). AHD, LHO, and JG all showed a consistent and statistically significant decline over time, with the joint gap decreasing by half. Consistently, smaller JG and AHD were correlated with lower SSV (p = 0.03 and p = 0.07, respectively). Massive loosening was associated with a 14.5 points lower SSV (p < 0.01). Finally, narrowing of the JG was significantly correlated with increased radiolucency (p < 0.001) and tended toward worse SSV (p = 0.06). In summary, radiographic parameters displaying medialization and cranialization after aTSA with a cemented pegged glenoid are useful predictors of impaired shoulder function.

Impact of Sports Activity on Medium-Term Clinical and Radiological Outcome after Reverse Shoulder Arthroplasty in Cuff Deficient Arthropathy; An Institutional Register-Based Analysis.

There is a lack of consensus on what physicians can recommend and what patients can expect concerning sports activity after reverse shoulder arthroplasty (RSA). The purpose of this retrospective register-based observational study was to investigate the association between participation in sports or physical activity involving the upper extremity and 5-year clinical and radiological outcomes for primary RSA patients. We screened the institutional arthroplasty registry for patients reporting the type and level of sports postoperatively after primary, unilateral RSA due to rotator cuff deficiency. One hundred thirty-eight patients with clinical and radiological outcomes documented at a minimum 5-year follow-up were divided into three groups comprising those who participated regularly in: sports mainly involving the upper extremity (sports upper extremities, SUE, n = 49), sports mainly involving the lower extremities (sports lower extremities, SLE, n = 21), and those who did not participate in sports at all (no sports, NS, n = 68). The participants had a mean age of 72 years (standard deviation (SD) 8) and were overall predominantly female patients (62%). Primary clinical outcomes included the Constant Score (CS) and Shoulder Pain and Disability Index (SPADI). Secondary radiographs were analyzed for radiolucent lines (RLL), signs of glenoid or humeral prosthesis loosening, bone resorption, bone formation, and scapular notching. A total number of 8 senior surgeons were involved in treatment of patients, and two types of prosthesis were used. The SUE group had non-significantly higher mean scores for CS (75 points) and SPADI (88 points) compared to SLE (71 and 78 points, respectively) and NS patients (66 and 78 points, respectively) (p ≥ 0.286). The incidence of RLL around the humeral diaphysis was higher in NS compared to SUE patients (32% versus 12%, respectively) (p = 0.025); all other radiological parameters were similar between the groups. There were no cases of loosening in the SUE group that led to revision surgery. Patients engaging in sports activities involving the upper extremity show similarly good functional scores 5 years post-RSA as the other groups, without additional signs of implant loosening as a result of increased shoulder use.

Deltoid flap reconstruction for massive rotator cuff tears: mid- and long-term functional and structural results.

BACKGROUND: Various open and arthroscopic techniques for irreparable massive rotator cuff tears have been described. Muscle-tendon transfers may be considered in order to improve range of motion and strength. MATERIALS AND METHODS: We assessed retrospectively the functional and structural results of 31 deltoid flap transfers for massive postero-superior rotator cuff tears at 2 time points: Mid- and long-term follow-up exams were performed after a mean of 53 and 175 months, respectively. RESULTS: Functional gains were minor, but improvement in pain and patient satisfaction was high. The mean Constant score improved from 31 preoperatively to 46 points at mid-term follow-up. At long-term follow-up, 16 shoulders were still available for exam and presented with a mean Constant score of 66 points. Survival rates of the deltoid flap, confirmed by ultrasound, were 16.5% at mid-term and 12.5% at long-term follow-up, and correlated with better clinical outcome. Cranial migration of the humeral head progressed in all cases and could not be prevented by the interposition of a deltoid flap. CONCLUSION: Based on the results of this series, we no longer use nor recommend this technique.

Short-term results after reversed shoulder arthroplasty (Delta III) in patients with rheumatoid arthritis and irreparable rotator cuff tear.

The purpose of this study was to describe the outcome after reversed Delta III shoulder prosthesis in patients with rheumatoid arthritis (RA) and irreparable rotator cuff tear. Fifteen patients (17 joints) were prospectively analysed using the Constant-Murley score (CS). Comprehensive outcome measure was carried out by means of four widely used questionnaires as well as clinical and radiographic examinations at an average of 24.3 months postoperatively. The CS improved significantly from 19 to 59.5 points. The mental (MSC) and physical (PCS) component summary score of the Short Form 36 (SF-36) reached 108% and 77%, respectively, while the DASH (Disabilities of the Arm, Shoulder, and Hand) was 58% of a comparative norm population. Remaining deficits were documented by SPADI (Shoulder Pain and Disability; 54.4 points) and ASES (clinical and patient-orientated American Shoulder and Elbow Surgeons; 84.3 and 61.3 points, respectively). No radiological signs of loosening were found, but scapular notching occurred in four cases. Reversed arthroplasty provides a substantial improvement of shoulder function in patients with RA. The high incidence of notching is of concern.

Shoulder Muscle Strength and Neuromuscular Activation 2 Years after Reverse Shoulder Prosthesis-An Experimental Case Control Study.

Although reverse shoulder arthroplasty (RSA) has shown successful postoperative outcomes, little is known about compensatory activation patterns of remaining shoulder muscles following RSA. The purpose of this experimental case control series was to investigate shoulder muscle strength and neuromuscular activation of deltoid and teres minor muscles 2 years after RSA. Humerus lengthening, center-of-rotation medialization, maximal voluntary strength, and electromyographic (EMG) activity were compared between the operated and the non-operated side of 13 patients (mean age: 73 years). Shoulder muscle strength was significantly lower on the operated side for external rotation (-54%), internal rotation (-20%), and adduction (-13%). Agonist deltoid EMG activity was lower on the operated side for shoulder flexion, extension, and internal and external rotation (p < 0.05). Antagonist deltoid coactivation was higher on the operated side for external rotation (p < 0.001). Large correlation coefficients were observed between shoulder adductor strength asymmetry and both center-of-rotation medialization (r = -0.73) and humerus lengthening (r = 0.71). Shoulder abduction strength and neuromuscular activation were well preserved 2 years after RSA, while persistent strength and activation deficits were observed for shoulder adduction and internal and external rotation. Additional studies are required to elucidate shoulder neuromuscular activation patterns before and after RSA to support decision making for surgical, implant design, and rehabilitation choices.

The Schulthess local Shoulder Arthroplasty Registry (SAR): cohort profile.

PURPOSE: Clinical registries are essential for evaluation of surgical outcomes. The Schulthess Shoulder Arthroplasty Registry (SAR) was established in 2006 to evaluate safety, function, quality-of-life and patient satisfaction in patients undergoing shoulder arthroplasty. PARTICIPANTS: Adult patients undergoing anatomic or reverse shoulder joint replacement at the Schulthess Klinik, a high-volume, leading orthopaedic surgery centre in Zürich, Switzerland. FINDINGS TO DATE: Between March 2006 and December 2019, the registry covered 98% of eligible operations. Overall, 2332 patients were enrolled with a total of 2796 operations and 11 147 person-years of follow-up. Mean age at baseline was 71 (range: 20-95), 65% were women. Most common indication was rotator cuff tears with osteoarthritis (42%) and the mean preoperative Constant Score was 31 (±15). The most frequent arthroplasty type was reverse, increasing from 61% in 2006-2010 to 86% in 2015-2019. Functional recovery peaked at 12-month postoperatively and did not show a clinically relevant deterioration during the first ten follow-up years. Since its establishment, the registry was used to address multiple pertinent clinical and methodological questions. Primary focus was on comparing different implant configurations (eg, glenosphere diameter) and surgical techniques (eg, latissimus dorsi transfer) to maximise functional recovery. Additionally, the cohort contributed to the determination of the clinical relevance and validity of radiological monitoring of cortical bone resorption and scapular notching. Finally, SAR data helped to demonstrate that returning to sports was among key patient expectations after reverse shoulder arthroplasty. FUTURE PLANS: As first patients are approaching the 15 years follow-up landmark, the registry will continue providing essential data on long-term functional outcomes, implant stability, revision rates and aetiologies as well as patient satisfaction and quality-of-life. In addition to research and quality-control, the cohort data will be brought back to the patients by bolstering real-time clinical decision support.